Failure to Maintain Fire Resistance Rating for Vertical Openings
Penalty
Summary
The facility failed to maintain the required fire resistance rating for vertical openings, specifically affecting two levels within the building. During a document review and interview conducted on March 17, 2025, it was discovered that the communicating stairway between the Lower Level Kitchen and the First Floor did not have the necessary one-hour fire resistive construction. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, the facility did not maintain the fire resistance rating for stair towers, impacting one of two floors within the building. A document review revealed that the north side exit from the Basement was a communicating staircase with walls not sheathed on the room 2A side, lacking the required one-hour fire resistance rating. This issue was also confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee. The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee.